Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Tuesday, January 15, 2008

There are lots of humans out there that I am amazed made it to adulthood. Witness one in particular...

A fortyish gentleman came in to see me the other night a full two months after being bitten in the foot by an Akita. His leg was swollen, red, and painful from the toes up to the knee. The infection had been evident a few days after the bite and by the time this gentleman figured out that it might be time to see a physician the question on my mind was whether we would be able to save his leg or not. The leg was tense and weeping pus. Make sense so far? Good.

This is where the ER rule that one must always think of the worst possible diagnosis first comes in handy, then again, it doesn't. This is actually where our specialty intersects with veterinary medicine. ER docs are often in the position of veterinarians as many of our patients are unable (due to stroke, baseline mental retardation, intoxication and the like) or unwilling (patients in police custody for example) to give us the whole story.

Then there are the patients who are not, technically, mentally challenged, but are, nonetheless challenged. This particular gentleman was all set for admission with a vascular surgery consultation to assess the viability of his badly infected leg when the following exchange occurred...

Pt: Doc, I think I broke my ankle.Me: Why do you say that sir?Pt: 'Cuz when that dog bit me it rolled on my ankle and it has hurt ever since.Me: Well sir, you probably didn't break your ankle if you have been walking on it.Pt: Well why does it hurt so much?Me: Because you have a terrible infection and that hurts right there, especially since two months after the injury your bone might actually be infected, and sir, you will be lucky to keep that leg... You should have come in a lot sooner. In fact, you should have come in that day!Pt: Well, for a while I could take care of the pain at home.Me: How did you do that sir?Pt: With stuff I had at home.Me: What stuff?Pt: I don't know, aspirin or something...

Hmmmm. Aspirin. Aspirin is a killer and it particularly kills children and old folks. Oil of wintergreen is particularly nasty and even a smidgen of it will kill a child due to its extremely high concentration of methyl salicylate. Athletes have died from skin absorption of salicylate laced balms used to treat local pain. Paradoxically, an acute ingestion of aspirin is, oftentimes, a lot less dangerous than chronic salicylism. It's a difficult diagnosis to make, especially the chronic form, and is often the culprit when elderly folks die, as physicians don't think to check for it and the patient doesn't think to mention it. It's just aspirin right? They sell it in huge bottles for $3 right? Even when the diagnosis is made patients often still die. A good summary regarding aspirin toxicity can be found here.

Back to my patient...

Me: Sir, do you have a ringing in your ears?Pt: What? (just kidding). Yes.

So the simple cellulitis patient had a random aspirin level of 90 (very high). Three hours later, after the patient showed an alarming decrease in his mental status, I had intubated him, and placed him on a ventilator. I scanned his head to check for cerebral edema, which was not present, and then placed a dialysis catheter in his femoral vein.

He went to the ICU, sedated on the ventilator, and was emergentlydialyzed. Three days later he remains on the ventilator. I have no idea if his leg will survive because the critical care team can not get him off the ventilator and don't know if he will survive. His two pack a day smoking habit is not helping in this regard.

Yet another example of the challenge of being in the ER. If I had not been curious about the 'broken ankle' comment, this man would have died and even an autopsy might have missed the problem. He may still die. Really, I was so amazed that he had waited so long I didn't hope to gain any diagnostic answers from this question, I was merely trying to get more information so I could tell his story later with the complete list of bad decisions he had made. (Yeah, I was going to make fun of him with other docs and nurses. Sorry.) His death could easily have been ascribed to sepsis, which he has, and his lab work was eerily normal. Chronic salicylism. Danger! Both he and I were lucky that night. Very lucky.

17 comments:

911Doc-Not being in the Medical profession, I know my opinion is a humble one at best, but, I think you are a great doctor and a good man. From your other posts, I have read that you are seriously considering leaving emergency medicine and I realize that you have to do what's best for you. But your leaving is definately emergency medicine's loss. What ever your decision, I wish you the best and hope that if I ever find myself in an Emergency Department,I will be blessed with a physician like you who is both excellent and compassionate.Take Care

I wrote a whole bunch if questions but I just confused myself even more. Thanks for sharing, I had no idea that aspirin toxicity even existed.

Your word verification salutes you. On a scale of 1-10, where do you rate 911?ametendr (ahm eh ten doctor) or, ametendr (ah, me ten doctor)It could be saying you're tender, but that would be too gayIn your defense, nobody could be gayer than House.

yes, it is a man thing. I have been to the dr and ER too many times for something I thought was of concern, and they find nothing wrong. I leave feeling like a fool so now I refuse to go to the dr. unless something is seriously impeding my life, and the pain is uncontrolled by ibuprofen. (I don't take aspirin.)

For example, I get chest pain a lot. Every day for the past 2 weeks. But i have no other symptoms, so I'm not going to the dr. I have also been diagnosed as the lining in my chest cavity being pinched, which causes the pain. My dad has this too. So there is no reason to think it is a heart attack or something else more serious.

dear chuckr44, go now, not tomorrow, not in an hour, to the ER to get an ekg and tell your story to someone like me. i am quite serious, until you get the CP explained by definitive tests you are a ticking time bomb. best.